Recently in National Health Reform Category

A recent subtext in the debate on health care reform has been about Medicaid's alleged failure to provide its enrollees with access to care - the argument goes that the parents and childless adults who would be added to Medicaid as a result of leading proposals would mean that 15-18 million people would be dumped into coverage where they wouldn't be able to see a doctor. As often is the case in Washington, the facts are considerably more nuanced than the talking points. 

First, research is very clear that Medicaid has increased access to care and reduced unmet health needs for both children and adults. In fact, in terms of primary and preventive care, access to care in Medicaid is approximately equivalent to that in private insurance. Access to care issues in Medicaid are more likely to arise in certain specialties (most notably such as access to dentist care) and in certain geographic areas and they most certainly exist. But having Medicaid has been critical in improving low-income children's access to needed care.

We're all aware (perhaps from our own experience of trying to find a doctor who will take our insurance) that having an insurance card does not necessarily ensure access to care. I have virtually given up finding an internist that will take my Georgetown University Blue Cross plan. Doctors and hospitals pick and choose which insurance plans they'll take.  A recent Center for Studying Health System Change survey asked physicians whether or not they were accepting new patients. Their answers varied by patient insurance type: 

Yes, there are more doctors who are not accepting any new Medicaid patients, compared with those accepting new patients covered by Medicare or private insurance. But overall, more than 70% of doctors are accepting at least some new patients covered by Medicaid.

Part of the issue with the slightly lower physician participation in Medicaid could have to do with lower reimbursement rates, which are about 72% of those paid in Medicare (and these rates are supposedly lower than private rates, but a true comparison is tough since that information is deemed "proprietary"). 

Now, people may legitimately say that adding an additional 15-18 million people to the program is likely to exacerbate access problems. It is true that adding that many people into the system requires consideration of the program's capacity to provide the care people will need. The most obvious solution -- an increase in reimbursement rates.

And there may be hope on the horizon for just such a solution. Following the health reform summit, the President has appeared to embrace this idea. The House included a provision in its health reform bill for a phased-in increase in Medicaid reimbursement rates and it also seems to have bipartisan support (Sen. Grassley (R-IA) raised it as an issue at the summit).

Medicaid has been instrumental in meeting the health needs of millions of children and families, and through health reform, the program would be expanded to meet the needs of millions more. So let's think about how to do that most effectively, but let's not use the access challenges, which happen in private and public coverage alike, to become an excuse not to do meaningful reform.

 Thanks to Martha Heberlein for helping with the research for this entry.

Having just survived a truly impressive tantrum this morning from one of my sons who was deeply committed to going to school this morning without shoes, I'm feeling primed for what promises to be a raucous final stage of the health reform debate. 

As far as we know, Congress is still proceeding with the plan of the House passing the Senate health reform bill (with many members kicking and screaming as vigorously as my son this morning), then the House and the Senate passing a smaller reconciliation package designed to improve the Senate bill and make it more palatable to House members.  I just hope we get through the week without anyone throwing shoes at an authority figure (at home or in Congress).

This week, RollCall reports that by the end of the week we may see the actual legislative language of the reconciliation bill and a CBO score, allowing us to fill in final details of what health reform might look like.  The White House continues to press for a final vote in mid-to-late March.

In the meantime, everyone is digging deeper on the arcane rules of budget reconciliation.  Our friends at CBPP have shared the gory details before, but the question of the day seems to be whether using reconciliation actually allows health reform proponents to proceed with a straight up-or-down vote.  The issue has flared up because there is a 20-hour limit on debate over a reconciliation bill, but the rules may allow opponents of health reform to offer an endless series of amendments OUTSIDE of the 20 hours of debate. If they take this route, Senate leaders will need to decide whether to call in Vice President Biden to declare the string of amendments "dilatory" and to dismiss them. 

Also, this week we'll be tracking where things are heading with a 6-month extension of Medicaid fiscal relief, which has enormous implications for the capacity of states to continue to sustain and strengthen their gains for kids and families.  The Medicaid fiscal relief is included in a jobs bill making its way through the Senate right now. To make things confusing, the term "jobs bill" has been used to describe three separate bills currently in motion: 1) a $17.6 billion package that mostly creates a tax credit for companies that hire unemployed people; 2) a short-term extension of unemployment insurance, COBRA and a few other items through end of March/early April (this is the one that Senator Bunning single-handedly held up on the Senate floor last week); and 3) a much bigger extension through December 31, 2010 of unemployment insurance, COBRA, and a few other items.

It is this THIRD so-called "jobs bill" that includes a 6-month extension of Medicaid fiscal relief from December 31, 2010 through June 30, 2011.  Congress Daily reports that the jobs bill (the third one) will be up on the Senate floor this week, and then it will need to go to the House for action. The House already has twice passed an extension of Medicaid fiscal relief in other bills and President Obama supports it, which means the prospects for passage are bright if it makes it through the Senate. 

Following last week's health care summit and release of his health care reform proposal, the President today urged Congress to end the debate and bring health reform across the finish line. In his remarks, the President painted a vivid picture of what it means to not pass health reform, including more uninsured families, additional people denied coverage because they are sick, and skyrocketing premiums. Yesterday, we reported on what doing nothing would mean to families.

The Proposal

The President did not release a revised health care proposal but said he will incorporate at least two Republican ideas brought forward at the health care summit. This includes sending in "secret shoppers" to Medicare and Medicaid providers to combat fraud and abuse (an idea offered by Sen. Coburn) and providing a funding appropriation of $50 million in state demonstration grants to find alternatives to resolving medical malpractice disputes (similar proposals have been included in Republican bills).

On Tuesday, the President also sent a letter to congressional leaders outlining two other ideas that he is willing to consider for inclusion. One idea was suggested by Sen. Barrasso to allow the Health Savings Accounts (HSAs) in the Exchange. 

The other idea (which was initially raised by Sen. Grassley at the summit) would address what the President acknowledged are "inadequate" reimbursement rates in Medicaid. Improving doctor reimbursement would help increase access to care for the millions of new families entering Medicaid under health reform. As you may recall, the House bill already includes a phased-in increase in Medicaid reimbursement rates (tied to those offered in Medicare) for primary care services, with the federal government picking up the tab for most of the increased costs. It is not evident whether this or a similar provision will ultimately make it into a bill but the President's recognition of the issue is a positive sign. 

We expect legislative language soon and will provide more details then.

Timing/Process

President Obama is expected to make his much anticipated health reform announcement at 1:45 pm today in the East Room of the White House.  He will be flanked by HHS Secretary Sebelius and health care professionals. He is expected to encourage Congress to move forward swiftly.  Say Ahhh! bloggers will share our perspectives following the event.

As leaders in Washington debate the future of a plan to get our nation's arms around the colossal health care system, it's worthwhile to take a look at how things would be different today if some past health reform efforts had succeeded.

What if ... President Nixon's plan had passed before he left office?  According to The Commonwealth Fund, if President Nixon's plan had passed, the United States might be spending a trillion dollars a year less than it does now.

What if....President Clinton's efforts to pass health reform had succeeded?  President Clinton's plan would have reduced spending by an estimated $500 billion a year according to The Commonwealth Fund report.  

What if ... this latest attempt to get a handle on the health care system doesn't succeed? 

•  Will typical family premiums double in ten years to $24,000 as predicted? 
•  Will the number of uninsured really increase from 49 million today to between 57 million and 66 million by 2019?
•  Will states struggle to meet the staggering increases in the number of people who must rely on Medicaid and CHIP for affordable coverage?People think if we do nothing, we will have what we have now," said Karen Davis, the president of the Commonwealth Fund in an interview with the New York Times. "In fact, what we will have is a substantial deterioration in what we have." 

If Congress and the Administration are unable to find a way to follow-through on health reform this time around, only time will tell how this missed opportunity would impact all of us, our children and our grandchildren. Let's hope they are able to rise to the challenge so future generations won't look back on this moment in history and think to themselves how much better life would be "if only ..."

5:30 pm Signing off

Thanks for taking the time to follow the health reform summit.  At CCF, we're anxious to hear your reaction to the summit and what it means for the prospects of health reform and its impact on children and families. For a transcript of the health reform summit, visit Kaiser health news. Don't forget to check out CCF's fact sheet on President Obama's health care proposal.

5:25 pm Health summit concludes

President Obama wrapped up the summit by saying there seemed to be broad areas where the two sides agreed but they had philosophical difference in approaches. The areas he mentioned were:

1) insurance market reforms (difference on how much or how little to regulate and whether or not to stop discrimination based on pre-existing conditions which hinges on requiring people to obtain coverage).

2) assisting small business owners and those trapped in the individual market (difference on whether or not risk pools would adequately serve people or whether they should be allowed to benefit from being in a larger pool such as an exchange which would bring down costs -- he compared the economic advantage of being in a larger pool to the advantage Walmart has in negotiating prices with consumers compared to small independent stores.)

3) allowing interstate purchase of health care (differences in whether or not to allow them to "race to the bottom" as happened with credit card companies or whether to ensure a baseline of coverage and consumer protection).
4) medical malpractice reform (approaches varied and actual savings questionable).
5) broad areas outlined by Senator Coburn such as eliminating waste, cracking down on fraud, reducing medical errors, encouraging price transparency and improving prevention (which President Obama pointed out were all in his proposal).

President Obama noted that for the first time, more people are getting health care coverage from the government and that it isn't due to actions by Congress or the Administration but due to the fact that employers are shedding health plans and people are losing coverage.  He said that now that the public option has been dropped, the debate is no longer about whether or not the bill represents a "takeover of the health care system" but revolves around "how much should we regulate the insurance industry". He described his experiences talking to the parents of uninsured children with conditions such as diabetes and heart conditions and said "they don't want us to wait".  He implored opponents of the health reform bill to do some "soul-searching" and decide if they were willing to work to get a bill passed.

4:20 pm Medicaid's role in health reform

The research on how people feel about Medicaid generally shows that they are very pleased to have it, and it has been a big boost to their families. According to a Kaiser Family Foundation study, fully 95% of low-income parents who know about Medicaid/CHIP think they are good programs. In addition, nearly 9 out of 10 with uninsured children say they would enroll them if it was a possibility, and the vast majority would be interested in enrolling along with their child.  So, we were a bit surprised to hear Representative Roskam (Ill.) say, "it isn't working for anybody" and shouldn't be used to cover more people because it is a "weak foundation."

As with all kinds of insurance, there are some issues with Medicaid, including that it often doesn't pay providers as much as other public programs (CHIP, Medicare). This is a solvable problem. The House bill addressed the issue by providing federal funding to bring reimbursement rates in Medicaid for primary care services up to Medicare levels.  (President Obama acknowledged the problem after Representative Roskam spoke, but, notably, did not include this improvement in his own proposal.)

Finally, we also were a bit surprised to hear President Obama say that very poor people already have coverage through Medicaid, which is superior to the options available to working families. In fact, Medicaid does not cover adults without children, even if they are living in deep poverty (unless they are lucky enough to live in the handful of states with special waivers to do so). And, in most states, parents are not eligible for Medicaid even if they are well below the poverty line. The situation is much better for children. Due to Medicaid expansions for children and the CHIP, children in poor and low-income working families generally can qualify for coverage. The result is that children are far less likely to be uninsured than their parents and other adults.

4:05 pm Barrosso argues for high deductible plans/HSAs
The sharp philosophical differences between the two parties on coverage issues are clearly on display in this final segment of the summit. Senator Barrosso, a surgeon from Wyoming, made a pitch for America providing the best health coverage in the world, citing a Premier of Canada recently deciding to come here for heart surgery. He argued that we could hold down health care costs if people had more information on health care costs and more incentive to be "prudent purchasers," such as provided under high deductible plans or HSAs. President Obama pushed back, arguing that most uninsured people in the United States aren't premiers or sultans and don't have much money with which to fill gaps in their health care coverage.

3:50 pm Moving to the topic of coverage - President's goal to cover 30 million uninsured 
They are getting close to wrapping up, and just reaching the topic of coverage. President Obama kicked off the discussion, framing it as: can America, the wealthiest nation on earth, do what every other advanced nation does - make sure that every American has health insurance coverage? Before turning over to Senator Barrasso (Wyo.), President Obama made a pitch for acknowledging the reality that you can't "waive a magic wand" and cover all of these people without it costing some money.

3:25 pm Debate over paying for reform continues
Discussion continues on what health reform would mean for our budget deficits if health reform passes, with Democrats arguing it will help immensely and Republicans taking the opposite position. Some of the most intense debate is over the appropriateness of using cuts to Medicare Advantage to help pay for reform. From a child and family health perspective, this part of the discussion can seem pretty far removed from what matters to kids and families. But, the question of how to pay for health reform, including major expansions in coverage for low-income families, long has been the key reason why it is so hard to enact.

3:00 pm Discussion turns to impact of health care on deficit
Vice President Biden discusses the impact of rising health care costs on the deficit and how we can "bend the cost curve." Representative Paul Ryan (Wisc.) agrees that it is right to frame the debate on high costs and health inflation. However, there is disagreement between the parties on whether the President's bill would reduce deficit (as the CBO as determined).

2:40 pm President says families with insurance already spend up to $1,100 a year on uninsured people
President Obama argues that "independent economists" think families with insurance already spend $1,000 to $1,100 on the cost of providing care to uninsured people. He says that, for example, the uninsured kid with asthma in Senator Coburn's example, might well get care, but that the ER bill would end up being being paid for by families with insurance. Citing this kind of cost-sharing as a reason why an individual mandate or "responsibility" is required, the President admits he's argued against such mandates on the campaign trail and had to be brought "kicking and screaming" to the conclusion that they were necessary.

2:35 pm Even the son of a Rockefeller can be uninsured
Senator Rockefeller (W.Va.) describes how his son, who was old enough to buy insurance on his own, decided that he didn't really need it. Instead, he chose to go without insurance, apparently on the theory that he wouldn't get sick. Senator Rockefeller says that such cases are one reason why the country needs to mandate that people secure coverage (and also that he and his wife insisted that his son buy coverage the next day). To help address the problem that young people often think they don't need coverage -- and also that they often don't yet make enough money to buy it -- one of the reforms included in leading health reform bills is whether to give families the option to add young adults up to age 25 or 26 to their parents' insurance plans.

1:33 pm Quotes to ponder while waiting for summit to reconvene

"You can always get cheaper coverage if it has higher copays, higher deductibles and limited coverage." (President Obama after pointing out that is one thing to get insufficient coverage on a beat-up car but another thing if it's health coverage for a child)

"How do we wring out waste, fraud, abuse and duplication from the system without interfering with the care that we want every person on Medicare, Medicaid and private insurance to receive?" (Sen. Schumer)

"We need a patient-centered, market-based approach." (Sen.Coburn)

"We are trying to give people choice and competition in the private sector but requiring the private sector to operate under a set of rules." (Secretary Sebelius)

12:59 pm Break for lunch/House vote  

Just as Washington is finally thawing out from under all the snow, it seems that health reform was dug out too with the release today of President Obama's health reform proposal.  The President's plan sets the stage for the bipartisan health reform summit that the White House is convening on Thursday. In an effort to add more transparency to the legislative process, the meeting will be streamed live.  For those of you unable to watch, we'll fill you in via this blog.

In his proposal, the President lays out a clear roadmap of policies that he wants included in a comprehensive health reform bill. The basic framework is the same as leading bills developed in Congress over the past year of debate: insurance market reforms, new health insurance Exchanges and subsidies for those who need help purchasing coverage, an individual mandate to obtain coverage (with exceptions for those at lower incomes and those paying too much in premiums), and a number of health care delivery and access initiatives. 

But, the new proposal adds improvements aimed at addressing concerns with the earlier congressional proposals, including provisions to strengthen the affordability of coverage, changes to the structure of the excise tax on high-cost plans, and new authority for the Secretary of HHS to monitor and, if appropriate, address sharp increases in health insurance premiums.

The President's proposal does not include legislative language so we don't have all the "nitty-gritty" details that some of us are eager for.  But, here is a quick read on where it lands on the key issues affecting children and families (CCF has also released a fact sheet on the proposal):

• Expands Medicaid up to 133% FPL and addresses some of the controversy over the financing of this coverage. The so-called "Cornhusker" fix, which gave Nebraska special help in coping with the new Medicaid costs, was eliminated. Instead, borrowing from both the House and Senate bills, all states would be eligible for a Medicaid matching rate (for those newly-eligible) of 100% for 2014 through 2017, 95% for 2018 and 2019, and 90% in subsequent years.
• States that have already expanded Medicaid to adults (up to 100% FPL) would receive a matching rate increase of eight percentage points "on certain health care services".
• CHIP would be continued through fiscal year (FY) 2019, with funding through FY 2015. States would receive a 23-percentage point increase in their CHIP match beginning in FY 2016.
• Stronger affordability protections (relative to the Senate bill) would be in place so that individuals and families purchasing coverage through the Exchange at 100% FPL would pay no more than 2% of their income and those at 300% up to 400% FPL would pay no more than 9.5%. Cost-sharing assistance would also be provided to families up to 250% of the FPL.
• Simplification measures for Medicaid, CHIP, and subsidies including using modified adjusted gross income (as in the House bill), a 5% income disregard for Medicaid eligibility to ensure coordination between the programs, and "seamless enrollment". Medicaid and CHIP individuals would enroll through "streamlined, easy to use, State-by-State websites".

With the release of the President's proposal, health care reform once again takes center stage. Stay tuned as we explore the implications for children and families. 

In this often-called "unprecedented" economic recession, it is easy to become jaded by the dire statistics thrown our way. This week however, the Kaiser Commission on Medicaid and the Uninsured (KCMU), gave us a positive number to consider:  over the last year, 3.3 million more uninsured people (2 million who were children) were able to rely on Medicaid for health coverage. According to KCMU, this was the largest one-year increase in terms of numbers of people in the history of the program.  When you think about it, it should come as no surprise.  Since most people receive their health coverage through their jobs, the current high unemployment rate equates to millions of families also losing health coverage. Fortunately for these families, they were eligible for Medicaid (or CHIP) and did not have to forgo doctor's visits for themselves or their children. 

But unfortunately, at the same time that many more families are seeking a safety valve to help them through these insecure times, states are facing their own economic uncertainties. Decreased revenues coupled with increased demand for services have put a strain on states, with a number considering Medicaid cuts just when families need it the most. A number of states have been able to hold the line due to a temporary increase in their Medicaid matching rate that was included in the stimulus bill. Since a condition of receiving the enhanced match was that states not cut Medicaid eligibility (referred to as a maintenance-of-effort requirement), the funding was critical in ensuring that the growing ranks of families needing Medicaid could obtain that care.

The KCMU report shows however that with the FMAP increase ending December 31, 2010, states are again looking at dramatic enrollment increases that they cannot sustain. As I previously described on this blog, the President's proposed budget includes a six-month expansion of the FMAP increase. There are also legislative proposals to do the same, including the House's inclusion of an extension in its "job's bill".  Families USA released a report this week that explains the positive impact the FMAP increase and the maintenance-of-effort requirement has had for families, and what they could lose if it is not extended.

Let's think about that number again: Medicaid enrollment increased by over 3 million individuals. That is a lot of families who are struggling, and it is wonderful that this help is available to them (and hopefully will continue to be). But lets also not forget the millions more who became uninsured but were not eligible for Medicaid or CHIP. We will report next week on the President's health care summit for solutions put forth to address the growing ranks of the uninsured.

In many cultures, the first birthday of a child is a major community celebration.  It signifies that the baby has made it through the critical first year and is now destined for great things.  

We should be celebrating the first year of the Children's Health Insurance Reauthorization Act (CHIPRA).  CHIPRA renewed the Children's Health Insurance Program (CHIP) and gave states new tools and fiscal incentives to enroll more uninsured children in CHIP and its larger companion program, Medicaid.  Unfortunately, for many of us, it just doesn't seem right to have a big celebration when there is so much uncertainty over the future of health reform.  I confess that I was reluctant to celebrate CHIPRA but when I thought about how the past year would have been without it, I came to my senses.  Without CHIPRA and the temporary increase in federal funding for Medicaid included in the economic stimulus package, the health needs of so many more children would have gone unmet. 

In the past year, while private insurance has become less available and more expensive and families faced the most difficult economic times since the Great Depression, the renewed CHIP program and Medicaid have offered a vital lifeline to America's children.  Thanks to the strong resolve of national and state leaders, many of our children have been sheltered from this economic storm.  

CHIPRA, and the increased funding for Medicaid, helped states strengthen and maintain their commitment to children's health coverage just when they needed it most.  While the financial investment was relatively small, it made a huge difference in the lives of the people it helped.  Just ask the Simpson family from Benton Arkansas who were able to maintain CHIP coverage for their children when Mr. Simpson lost his job as an electrician. 

This is but one example of the lives touched by the positive actions of national and state leaders to sustain and strengthen children's health coverage over the past year.  Families with children who had asthma, diabetes or autism who couldn't afford private insurance had access to health coverage so they could get their children the treatment and preventive care so crucial to their well-being.  Parents who lost their jobs and health insurance were able to turn to CHIP or Medicaid to secure coverage for their children.  (It would be better for the entire family if the parents also had access to stable, affordable health coverage that didn't disappear when they lost their jobs but we'll have to wait for broader health reform to make that improvement to the health care system.) 

CHIPRA was not intended to solve all of the gaps in our health care system but was designed as a bridge until our nation's leaders were able to pass broader health reform.  While the timing of health reform is uncertain, one fact remains clear - children and families need access to secure, stable, affordable health coverage that won't be taken away if they lose a job or become sick. 

So what should we give CHIPRA on her first birthday?  How about a sibling named Health Reform?

"...let's talk about honoring our most important responsibility as Iowans. That is, our duty as parents, and as shepherds of our children's future. You know, I'm proud of the fact, that working together, we've made a long-term investment in the health and education of "all" children... Together, we must continue this investment, and my budget will reflect this."


I recently returned from maternity leave and had no idea what the state of children and family health coverage would be given the protracted battle on health reform and the challenges facing state budgets. I was pleasantly surprised to see that while there is still a lot of anxiety about current state budget woes and health care reform, that many lawmakers, like Governor Culver, are vigorously defending the improvements they've made for children's coverage in recent years.